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CLINICAL SOCIETY OF LONDON.

Fracture of the Spine treated with Sayre’s Tac7,et. -Excisionof the whole l’o2igite. -Bound-celled Sarcoma of the Thightreated by Amputation at the Hip-joiibt. -Bronzed Skinwithout Constitutional Symptoms.THE ordinary meeting of the Clinical Society was held on

Friday, March llth, J. Lister, Esq., F.R.S., in the chair.Mr. BERKELEY HiLLshowedayoungman who had had a frac-

ture of the Lower Dorsal and Upper Lumbar Vertebrse treatedwith Sayre’s jacket, and who had recovered with only slight

- deformity of the spinal column. The patient fell twentyfeet, and sustained fracture of the laminae of the tenth dorsalvertebra and others, as far as the second lumbar. Therewas angular projection of these spines, and mobility of twoof them. On admission to University College Hospital hesuffered from severe concussion of the brain and spinal cord;next day he was in severe pain. Twenty-four hours afterthe injury he was placed on a table swinging at the middle,and on it raised and suspended by his head and shoulders, anda plaster jacket applied. There was immediate relief tothe patient’s sufferings, and no bad symptom followed, ex-cept loss of control of the left lower extremity for aboutthirty-six hours, and temporary extreme hypersesthesia of apatch of skin on the dorsum of the same foot. The jacketwas removed seven weeks after the injury. Now, 101

days after the accident, he can walk ; his spine isstrong, and the only sign of the serious injury is a

moderate projection of the lower dorsal and upper lumbarspines and displacement of the laminse of the eleventhdorsal and first lumbar backwards on the right side.-Dr. BUZZARD observed that the patellar tendon reflex wasmuch exaggerated on the left side, and that he had ankle orfoot clonus on That side too, which is like that found inPott’s disease, where the paralysis is due to inflammation ofthe cellular tissue under the dura mater leading to a slightspinal myelitis. This lad has therefore some interferencewith the transmission of motor impulses up the lateralcolumns of the cord, probably from callus under the duramater at the seat of injury.-Mr. LISTER thought the mobi-lity of the spinous processes very interesting; traumatic acutespinal curvature, which is most often without paralysis, isproduced by fracture of the bodies of the vertebra, but herein addition to this there was injury to the spinous processes.It is impossible to say how this was produced; the curvemust have been produced by a fall on the breech or head.He had never seen the spines injured from this cause. Theresult of the treatment in this case was most satisfactory; in

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ordinary cases the recumbent posture is sufficient.-Mr.H. BAKER asked if Mr. Hill found the jacket useful whenthe man was up and about.-Mr. B. HILL considered thatthe youth had struck his spine in falling. He was keptin bed for three weeks, but the jacket was worn altogetherseven weeks.

Mr. BARWELL showed a case on which he had performedExcision of the whole Tongue by means of a small supra-hyoid wound, and remarked on the best material for theloop of ecraseurs. James A-, aged sixty, withoutparental history of cancer, had enjoyed good health till ayear ago, when a small lump appeared at the side of histongue. This was twice removed by ligature, probably in-adequately, since on each occasion it quickly recurred.Admitted into Charing-cross Hospital on Feb. llth, 1881,the whole tongue almost to the foramen csecum was coveredby an ulcerated, very dendritic growth, interspersed withdeep ulceration. Saliva was constantly flowing from hismouth, and wetting his clothes. He was feeble from diffi-culty in eating, and had lost flesh ; pulse 108, small andweak; no enlarged glands. The growth is the result of lessthan seven months. Two days later the tongue was ex-cised. An incision about one-third of an inch long just infront of the hyoid bone exposed the raphe of the mylohyoid,which, being divided, bared the edge of the genio-hyo-glossus. These muscles, separated with the handle of thescalpel, enabled the operator to feel the base of the tongueand the deep surface of the buccal mucous membrane.A Liston’s needle passed into the wound entered themouth just behind the left last molar tooth, the thread beingleft. The same was done on the right side, the loop of thecord being in the mouth. To the first cord the end of an

ecraseur wire was tied and so drawn into the mouth, its endbeing freed from the first thread was hooked into the loop ofthe second and drawn round the back of the tongue, out ofthe wound, and fastened to the ecraseur. A Liston’s needlewas then passed into the wound through the middle of the-tongue, and, guided by the operator’s finger, was made toemerge well behind the disease. This needle guided thewire as it was tightened along the required line. As soonas the back of the tongue was thus severed, another ecraseurwas placed behind the incisor teeth, and its loop passed welldown in the previous section. Thus the tongue was freedfrom the floor of the mouth and taken out from between thelips. If the ecraseur be slowly used the operation is almostbloodless, and leaves no external scar or mutilation, and thetongue can be removed from immediately in front of the epi.glottis with as much ease as the tip. As the sensory nerves aredivided close to the jaw, the patient suffers hardly any painafterwards. The wires supplied by instrument-makers areof steel, and tempered ; they are too stiff, and the twistedwire-cords are not reliable. The soft iron wire used forpark fencing, and supplied by Messrs. Newali, makes a

very strong ecraseur loop, and is so flexible as to be verymanageable. Mr. Barwell also recommended the use of an.écraseur which tightened the loop from both ends. Thepatient was shown. The stump of the tongue was in verygood condition, cut off clean at the back. His generalhealth had improved since the operation. He got up on thetenth day, and was ready for discharge two days later, butwas kept in a few days longer.-Mr. HEATH thought thegreat objection to Mr. Nunneley’s operation was the veryoblique section of the tongue. Mr. Barwell’s operation gotover this difficulty no doubt, but he thought it better todivide the sublingual tissues first with the knife or scissors,The tongue can then be drawn well forward, and its sectionfar back easily made. Mr. Barwell’s wire was good. It isvery remarkable how the stump of a tongue grows. He hadlately seen a case in which he had operated ten years ago,removing all the tongue. The appearance was as if noneof the organ had ever been removed. — Mr. M. BAKEE

thought that in all the operations like Mr. Barwell’s it wasimpossible to prevent an oblique, and therefore unsatisfactorysection of the tongue, especially in a diseased tongue,through which the needles placed in any position are readilypressed forwards. Where the disease has spread from thetongue it is better to strip up the mucous membrane fromthe floor of the mouth very treely. He was at a loss to seehow the nerve could be divided so as not to leave its centralend sensitive.-Dr. POORE said the man talked uncommonlywell ; he could say " theatre " and " tittle-tattle, which re-quire tongue movement.-Mr. BARKER asked why this opera-tion is regarded as painless. Did Mr. Barwell consider thisdifferent from Cloquet’s operation proposed fifty years ago.He also asked if this form of papilloma is often met with; hehimself had only seen it once in a case under Mr. Marshall,at University College Hospital.-Dr. GILBART SMITH statedthat he had recently had a patient with large papillarygrowths on the back of the tongue, one or two ofwhich had entangled the epiglottis and caused diNi-culty in swallowing. He had seen other similar cases.-Mr. LISTER thought the wire more satisfactory than othersat present used. It combined pliability with sufficientstrength. If the whole tongue was removed, the amountat present seen in the mouth was most striking; perhapsMr. Baker’s suggestion of the oblique section explained it ;at any rate, the man had now a good two-thirds of thetongue. This was certainly a great improvement on Mr.Nunneley’s operation. In cases of the removal of the wholeor one-half of the tongue, he had found division of the jawin the middle line most satisfactory ; it is easy then tocontrol the artery and to limit the excision. With otherplans he had found it difficult to be certain of taking awayenough without removing too much.-Mr. BARWELL repliedthat he had never performed Syme’s operation. The periodof recovery after it was very long, and the proceeding wasaltogether very severe. Much blood may be lost by severingthe base of the tongue in Paget’s operation. This man lostone to one ounce and a half of blood, which was more thanusually happens in his own operation. The operation ispainless, because the nerve is cut close to the gustatorygroove, and retracts away from irritation. If a large Liston’sneedle is used to fix the ecraseur and firmly held it does notslip ; the specimen showed the section to be quite straight.When the man left the hospital there was no appearance ofthe mass of tongue seen now, but a square gap reaching far

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back. He had no distinct recollection of Cloquet’s operation,but he thought that in it a twine ligature was passed throughthe middle of the tongue.Mr. BERKELEY HILL related the sequel of a case of

IRound-celled Sarcoma of the Thigh, treated by amputationat the hip-joint, in which the whole of the anterior flapsloughed, which he recorded in the Clin. Soc. Trans. Thewoman died six years after the operation from tuberculouspyelitis, which, during the last three months of her life,caused an abdominal tumour, which was mistaken for a newformation of the original growth. There were no growthsof sarcoma found in any of the organs or tissues.-Mr.LISTER remarked on the great interest of the case, inasmuchas round-celled sarcoma is regarded as the most malignant formof sarcoma, but this was an example of its complete cure bylocal removal. It showed that our knowledge does not warrantus in speaking with certainty about the clinical history ofany tumour from its histological characters ; we are onlywarranted in stating the probability and the average courseof such tumours ; even a fibroma may prove malignant.

Dr. RADCLIFFE CROCKER read a case of general Bronzingof the Skin without constitutional symptoms, which hadbeen shown at a previous meeting. The patient was a sailor,a native of North Sweden, aged twenty-two, of stout build,and in good health. The pigmentation came on after ex-posure to severe weather eight years ago, attained its fulldevelopment in a few days, and has not extended or dimi-nished since the first week, though he thinks he is palersometimes than at others. The skin of the hands, backsof forearm, legs below the knee, and the mucous membraneare unaffected, but all the rest of the body is darker. The

pigmentation has no sharp line of demarcation on the limbsand face, but shades off to the normal. The general hue was ayellowish-brown; but the neck, axilla, nipples, umbilicus,penis, and scrotum were brown or black. The abdomen andinterscapular scapulae were darker than the general hue;while the man who is on duty at night is supposed to be readyat a moment’s notice. On the neck and axillae were closely de-veloped papillary growths about one-eighth of an inch long,and the natural lines of the skin were everywhere developed.Repeated alkaline baths and friction had no effect upon thediscolouration. Microscopical examination of the skin of theabdomenshowed the pigment to be deposited in the deeper cellsof the rete, though pigment granules were to be seen both inthe layers above close and to the papillary vessels of thecorium. The corneous layer encroached upon the interpapil-lary part of the rete mucosum, so that that part formed anarrow layer of uniform thickness moulded upon the friltse,which were elongated apparently by protrusion downwards ofthe interpapillary processes. The papillary growths upon theneck consisted of an oval growth of the papillary layer ofcorium, involving several elongated papillae. The pigmentwas in the same position as elsewhere, but there was noalteration in the arrangement of the epidermic layers. Dr.Crocker was unable to offer any satisfactory explanation ofthe pathology of this condition, but negatived the idea ofits being due to phtheiriasis, as was suggested when the casewa.s f1nown to thp. Sr<ct.RtvDr. CARRiNGTON showed a case of Bronzed Skin without IConstitutional Symptoms. J. B--, aged twenty-five, a

native of Dantzic, was admitted into the Seamen’s Hospitalon February 16th, 1881. He did not become a patient onaccount of the condition of his skin, but for an attack ofacute bronchitis. The patient left India during July, 1880.He had a very rough and lengthened voyage, and was con-tinually wet through. About the eighth or ninth week outhe began to suffer from severe pruritus, the parts affectedbeing the back and arms. At this time he changed hisclothes, and he maintains that his skin was then white asusual. On the second day he again changed his clothes,and he then found that his skin had turned brown. It wasalso dry and stiff, and on attempting to nip it between thefingers it cracked. His gums and teeth at the same timewere perfectly normal. About a fortnight after he noticedan eruption of small pimples on his arms and legs ; thesebecame little blisters, and exuded fluid on their rupture.These latter ran.together. His limbs assumed the appear-ance of being scalded. The weather was very wet and coldat the time of the attack, and there was no sunshine. Thepatient remained much the same up to the 15th week, whenswelling of the legs supervened. In October, 1880, he landedat Rotterdam, and was there treated for three weeks byarsenic. He again took ship, and in October, 1880, hebecame a patient in the Newcastle Infirmary. He was

there told that he was suffering from scurvy; but none ofhis shipmates had contracted that disease. Whilst in theinfirmary he was treated with sulphur baths twice a day fora month, and was made to lie in bed between blankets.The colour of his skin did not alter during his stay. OnFeb. 16th, 1881, he was admitted into the Seamen’s Hospitalfor an attack of acute bronchitis. There is no history ofsyphilis. A year ago he had an attack of ague lastingthree days. On admission he presented the appearanceof a well-nourished muscular man, with black hair andblue eyes. His skin was dry and harsh, but fairlypliable. It was, with the exception of the face, hands,and feet, stained of a medium walnut-brown colour. Therewas a diffused uniform tint, mottled with a darker shade ofbrown. The colouration was more uniform on the trunkthan on the extremities, where it became somewhat patchy.The areolae of the nipples were very dark, and the axillaeand genitalia were also somewhat more deeply stained, butcertainly not to a marked extent. He had also a well-marked attack of scabies affecting his feet and hands andbuttocks. There was no pigmentation of the mucous

membrane of the mouth and pharynx. The heart soundswere well marked and distinct. He had the physicalsigns of bronchitis. The liver dulness reached twoinches below the costal margin. The spleen was not en-larged. The above description applies to him now equallyas well as on admission, except that his scabies has beencured by treatment with sulphur ointment and baths. Hefeels perfectly strong and well-as indeed he has all along,except for his pulmonary trouble. A thin section of thesuperficial part of the skin showed abundance of pigment inthe epithelial cells, but no fungus. A patch on each side ofthe chest has been well treated with a saturated solution of

hyposulphite of soda, but without effect. With regard to apossible suggestion that the colouration was due to scratchingfrom the irritation of the scabies, Dr. Carrington did notthink this probable, both because the limits of the pigmen-tation far exceeded those of the supposed cause, and alsobecause it was almost certain that he could not have beensuffering from this affection all the time, the baths atNewcastle would then have cured it. This was the moreprobable, as he had rapidly recovered from this part ofhis trouble whilst under treatment at the Seamen’s Hospital.The scabies had most probably been contracted at a laterdate. On his admission at Greenwich he was certainly notscorbutic; his gums were perhaps a little pale, but therewas no haemorrhage. Neither was it possible that the pig-mentation was due to the slight attack of intermittent fever,for it is only found in the severe chronic cases.-Mr. LISTERsaid both the cases were very remarkable, from the suddenadvent of the bronzing without any constitutional disturb-ance.

The meeting then adjourned.

MEDICAL SOCIETY OF LONDON.

Annual Meeting.-Diarrhaea in Phthisis.-Defeets of Visionfrom Railway Collision.

THE annual meeting was held on the 7th inst., F. J. Gant,Esq., President, in the chair. The report of the Council wasread and adopted, and the ballot for the election of officersand Council for the ensuing year was taken, when thefollowing were declared elected :-President : Dr. Broad-bent. Vice-presidents: Dr. Wiltshire, Mr. J. W. Barnes,Dr. Quain, Mr. Brudenell Carter. Treasurer: Mr. FrancisMason. Librarian : Mr. Royes Bell. Secretaries in ordi-

nary : Dr. Gilbart Smith, Mr. Edmund Owen. Secretaryfor foreign correspondence : Dr. Berkhart. Council: Mr.H. F. Baker, Dr. Percy Boulton, Dr. Bucknill, Dr. SidneyCoupland, Mr. Hamilton Craigie, Mr. Cumberbatch, Dr.W. H. Day, Dr. T. S. Dowse, Sir Joseph Fayrer, Mr. F. J.Gant, Dr. Clement Godson, Mr. D. H. Goodsall, Mr.Alfred Pearce Gould, Dr. W. R. Gowers, Dr. F. de Havil-land Hall, Mr. Malcolm Morris, Dr. Heywood Smith, Mr.W. F. Teevan, Dr. J. C. Thorowgood, Dr. C. TheodoreWilliams, The subject for the Fothergillian E<say for 1883was announced-viz., "The Treatment of Thoracic Effusion."The ordinary business was then proceeded with.

Dr. C. THEODORE then read a paper " On the PathologicalTreatment of Diarrhcea in Phthisis." He enumerated three